Low Back Pain in Cycling: The Experts View.

The season is fast approaching and people are getting back into training. As with any sport, injuries are an inevitable risk. One of the most common injuries seen in cyclists of all levels is low back pain, with the literature suggesting it accounts for up to 45% of all injuries reported in cyclists. Therefore it's a good time to speak with some of the leading experts on managing low back pain and injuries suffered from cycling to see how it can be prevented and allow you to go through the year injury free.  

Bryan McCullough from Pure Sports Medicine organised a great meeting of minds at Bespoke including top consultant spinal surgeon Alexander Montgomery from London Sports Orthopaedics and Team Sky's Sports Doctor Phil Riley who also practices at Pure Sports Medicine. We ran through the Bespoke fitting process and bounced around ideas about cycling and back pain. It was a very productive and enjoyable evening. Below are each experts thoughts on lower back pain in cycling and the role of each professional in its treatment.

From Left to Right: Ben Hallam, Alexander Montgomery, Bryan McCullough, Phil Riley 

Low Back Pain and Cycling - Part 1 - A Sports Spinal Surgeon’s View 

Mr Alexander Montgomery – Consultant Spinal Surgeon, London Sports Orthopaedics 

Most of us have high pressured desk jobs, and use cycling both as a way of improving fitness, as well as a form of relaxation. The benefits are undoubted, but what most of us don’t realise is that it can often cause problems with your back or neck. 

According to a study in the International Journal of Sports Medicine, California State University researchers questioned 518 recreational cyclists and found 79.1% reported neck or back problems, almost twice that of any other joint in the body. Perhaps the most worrying finding was that just 36% sought any professional help to ease the pain. One interesting study was done by the British Cycling Federation on the squad medicals of its elite cyclists, and found that 60% of the 500 elite riders had low back pain. 

What most of us don’t realize is that the process of spinal disc and joint ‘degeneration’ begins from your mid to late twenties. The discs act as shock absorbers to the bones, they give flexibility, and maintain the height between two vertebra to allow the nerves to pass from the spine down to the legs. In this process the water and protein content of the centre of the disc decreases, and with it the shock absorbing capacity, flexibility, and space for the nerves to pass to the legs. The facet joints therefore take more stress, and they then start to degenerate. In order to take the extra stress placed upon them, the joints and ligaments react by getting larger, and in turn can start pushing against the nerves going down the legs (sciatica) and arms (neck). Alternatively, the disc can come out from between the bones, prolapsing and causing pressure on the nerves as well. 

Many of us have some or all of the above mentioned changes in our spine without having any symptoms, so we are therefore unaware of this. The pressure in the disc is lowest when lying down (sleeping), intermediate when standing, and highest when sitting and flexed forward, especially with a weight in the hands. You can then see why sitting at your desk the whole day bent forward, and then cycling, can put a great deal of stress on your back. Cycling can trigger symptoms in our spine that have been manifesting for some time. 

My role is to: 

1. Do a thorough and formal assessment of your back and your spinal nervous system, both for a provisional diagnosis of the problem, and to ensure there is nothing unusual or worrying occurring in your spine. 

2. Ensure you have followed and exhausted all conservative ways of dealing with your pain, and have been through your life with a fine toothcomb to seek the exacerbating factors of your current symptoms. 

3. Request an MRI of your spine when indicated to obtain the detailed anatomy of your spine for a formal diagnosis. 

4. Recommend any intervention if it is indicated and all conservative measures have been exhausted. 

Treatment Options if Conservative Management Fails 

Spinal Injections: 

These can be broadly divided in to nerve root (formainal) injections for leg or arm pain, facet joint injections (for facet based back pain, and caudal epidurals. These are done under sterile conditions, and using image guidance to ensure positioning of the needle. 

The purpose of these injections is to reduce the inflammation causing pain in your back or limbs, and allow you to get back to working on your bike position, posture, and core muscle strength in a pain free manner. It breaks the pain cycle, makes you feel more positive about your progress, and gives you a chance to persist with more conservative measures for a longer period of time . 

The injections and extended rehab programme can be tried more than once. If, however, this has failed, which it sometimes does in a small percentage of people, then surgery may need to take place. 

Surgery: 

For leg pain can be done in a minimally invasive manner with the aid of a microscope. This is known as a Microdiscectomy, where the disc that is putting pressure on the nerve is taken away. 

Surgery for persistent pain or weakness in the arms normally involves a small incision at the front of the neck, again using a microscope to take the disc away. Often an artificial disc replacement can be put in it’s place, but sometimes a fusion has to be done. 

Surgery for back pain is more complicated, and will involve a much more extensive rehab programme not only for those treatments already mentioned, but looking at all aspects of your lifestyle including your nutrition, work / life balance, smoking and / or drinking habits. 

Low Back Pain in Cycling - Part 2 – A Bike Fitter’s View 

Ben Hallam – Former GB Track Cyclist, Bike Fitter at Bespoke Cycling London 

During my racing career, I was dogged with recurring episodes of lower back pain which ruined my preparation during a number of seasons. This, however, is a common story throughout the professional peloton: Clarsen and Krosshaug (2010) found the 45% of the injuries reported by professional riders were lower back issues and a common story can be seen in recreational cyclists (Marsden 2010). 

A survey of recreational riders by Schlutz & Gordon (2010) indicated that riding more than 160km per week increases the risk of lower back pain by 3.6 times. But what can we do to minimise the risk? Adjusting the bike set up is certainly one piece of the puzzle. 

At Bespoke, we use a 3D motion tracking system called Retul to measure all of the body angles and movements that the set is creating. We then combine this with information from the body assessment to adjust the set up. Bars that are too low and/or too far away can cause increased lumbar flexion which is a contributing factor to lower back pain (Marsden 2010, Van Hoof et. al. 2012). Correct saddle selection is very important as increased perineum pressure can lead to altered hip angles and lumbar mechanics (Bressel & Larson 2003). Incorrect set up of these contact points can lead to potentially negative changes in the activity levels and control of our trunk and leg muscles (Van Hoof et. al. 2012). While adjusting the saddle angle has been shown to help relieve lower back pain in some cases (Salai et. al. 1999), changes in saddle angle have not been shown to correct the altered muscle activity (maladaptive motor control patterns) associated with lower back pain (Van Hoof et. al. 2012). 

Therefore, it is my belief that changes in bike set up need to happen in tandem with corrective exercise and suitable rehabilitation to correct cycling posture and increase a rider’s core stability. 

Low Back Pain in Cycling – Part 3 – A Sports Physiotherapist’s View 

Bryan McCullough – Specialist Musculoskeletal Physiotherapist at Pure Sports Medicine 

Musculoskeletal screening performed by a specifically trained physiotherapist can help to address any potential factors that may contribute to developing low back pain from cycling. This may range from inadequate flexibility of certain muscles and joints to weakness in certain areas, particularly the spinal extensor muscles and muscles of the core (O’Sullivan 2006, Abt 2010). A specific conditioning program can then be tailored to the rider covering the necessary components of muscle balance, core strength, and flexibility. 

However, we are more likely to see people when they come into our clinic having developed back pain already. In this instance it is of utmost importance to establish which tissue structures have been injured or being placed under excessive strain. Once this has been established we then must work backwards and establish the contributing factors that have led to the development of the pain in the first place. Treatment may then range from joint mobilization, soft tissue release, acupuncture and dry needling, to the development of a specific rehabilitation program to address the needs of the rider. 

Research into the origins of lower back pain in cyclists has identified a number of factors that are linked to the development of low back pain: 

Altered activation and control of trunk muscles (Burnett 2004, 2007) 

 Reduced endurance of spinal extensors (O’Sullivan 2006) 

 Incorrect saddle angle (Marsden 2010) 

Incorrect fit of certain parameters of bike (Marsden 2010) 

From the short list above we can see that low back pain in cyclists will often necessitate a multidisciplinary approach to fully address the problem. The greater the volume of cycling undertaken the greater the importance of an individualised bike fit. If the cause of the pain or dysfunction is not fully elucidated from clinical examination or the pain is severe and resistant to treatment it may be necessary to arrange referral to either a sports doctor or orthopaedic surgeon with experience in the field. In this way we can work closely together to find the solution and get the rider back on their bike as soon as possible. 

Low Back Pain in Cycling – Part 4 – A Sports Doctor’s View 

Dr Phil Riley – Sports Doctor at Pure Sports Medicine and Team Sky Procycling 

A typical patient may present with gradual onset low back pain, commonly related to having just taken up the sport, or having a recently increased training load. The medical assessment would incorporate a full medical history including previous musculoskeletal problems, a detailed activity/sporting history and family history. 

A general enquiry into associated symptoms may reveal a complaint of pain or pins and needles down the back of the leg, and this may be a sign that the sciatic nerve is being trapped or stretched. This may be as a result of the above predisposing factors, or maybe due to pressure within the piriformis muscle, which lies deep to the gluteal (buttock) muscles, and which can be compressed against the saddle of a bike, or possibly even a disc prolapse or bulge. Additional biomechanical factors such as leg-length discrepancy, spinal posture and poor core stability can exacerbate any potential problem, which in turn can be compounded by excessive load, for example hill-riding or using big gears. 

The role of the Sports Doctor is to evaluate the cyclist, hopefully prior to the onset of injury or pain, and therefore be in a position to prevent musculoskeletal problems. Inevitably, however, virtually all ‘patients’ will present with established symptoms, and the Physician has to establish the cause of the problem, advise regarding the need for investigation, and refer for appropriate treatment, which is likely to be in the form of physiotherapy, chiropractic or osteopathy.